Nursing for the People with lifestyle-related diseases in ... · •Health education, health consultation, functional training, visiting guidance •Specified health examination,

Nursing for the People withlifestyle-related diseases in

Japan

Japanese Nursing Association

2. Nursing for the people with lifestyle-related diseases: health promotion, prevention and supporting the persons

living with the lifestyle-related diseases

1. Current state of lifestyle-related diseases/NCDs in Japan and actions taken

2. Nursing for the people with lifestyle-related diseases: health promotion, prevention and supporting the persons living with the lifestyle-related diseases

3. Japanese Nursing Association in Action (to be issued soon)

2Japanese Nursing Association

Glossary• Lifestyle-related diseases：

It is a group of diseases that onset and progress of which are concerned with lifestyle and behavior factor(s) such as dietary habits, physical activities, rest, smoking , alcohol consumption, etc.

Examples: Diabetes, hypertension, heart diseases, cerebrovascular diseases, cancers, etc.

Japanese Nursing Association 3

Source: Ministry of Health and Welfare, the Council on Public Health on December 8th, 1996

ACTIVITIES IN THE COMMUNITY


Prevention and health promotion in the community

• Number of public health centers: 490• Number of municipal health centers: 2,421

(As of April 1, 2014)

Source: Office of Community Health, Division of Cancer Control and Health Promotion, Health Service Bureau, Ministry of Health, Labour and Welfare(MHLW)http://www.mhlw.go.jp/stf/seisakunitsuite/bunya/tiiki/index.html (Accessed December 18, 2014)


National and local governments implement policies for the purpose ofmaintaining and promoting health of community residents. Pursuant toa provision in the Community Health Act, local governments acrossJapan establish public and municipal health centers.Public health centers are regional bases for specialized and technicalservices to support the health of the community residents such asdisease prevention and advancement of hygiene standards. Prefectures,designated cities, core cities and special wards run public health centers.Municipal health centers provide comprehensive health services in closerelation to the community residents such as health consultations, healthguidance and health checkups

http://www.mhlw.go.jp/stf/seisakunitsuite/bunya/tiiki/index.html

Public Health Nurses take a role in prevention and health promotion


Public Health Nurses (PHNs) work at a public or municipal health centersall over Japan. To become a PHN, one needs at least one extra year oftraining in addition to basic nursing education. The PHN, as a specialistin public health nursing based on health promotion principles, takes theapproach of community activities by getting into community. Throughthe activities, the PHN identifies common health issues in thecommunity. The PHN seeks the path to finding solutions for the issues,while valuing the partnership and collaborating with the residents.In the community, the PHN supports people’s autonomous efforts topromote health and acquire self-care skill. The PHN’s work includeshelping individuals promote their health by improving individuals’selfcare abilities in such ways as providing information, as well as agroup-based approach including support of the mutual actions ofselfcare by the community residents.

• Number of full time PHNs working at public and municipal health centers in Japan: 24,668

Source: 2012 Report of Community Health and Health Promotion Programs, MHLW

Regulations and activities concerning lifestyle-related diseases

Health Promotion Act: health consultation, adult health

examination program, nutrition improvement program,

health promotion program, formulation of a health

promotion plan, etc.

Act for Assurance of Medical Care for Elderly People:

specified health examination program, specified health

guidance program, etc.


PHNs in the community carry out various activities to prevent lifestyle-related diseases and maintain residents’ health while paying attention tonational policies and identifying health issues in the community.Pursuant to the Health Promotion Act, the fundamental policies tocomprehensively promote citizens’ health was revised in 2012. Therevision also clearly indicates the prevention of the manifestation andexacerbation of lifestyle-related diseases (prevention of NCDs) as part ofthe policies.PHNs are engaged in a wide range of programs such as providinginformation on the prevention of the onset/exacerbation of lifestyle-related diseases, and the maintenance of health, as well as individualhealth education tailored to each individual’s needs, working as a teamwith other concerned professionals, including physicians and dieticians,as they are involved in planning and program design, implementationand evaluation.The Act on the Assurance of Medical Care for Elderly People hasobligated health insurers to provide specific health examinations andspecified health guidance for those aged between 40 and 74 targetingmetabolic syndrome since 2008. The PHN plays an important role inproviding health guidance as follow-up of the health examination.

Specified health examinations for persons covered by the National

Health Insurance

0

500,000

1,000,000

1,500,000

40-45 45-49 50-54 55-59 60-64 65-69 70-74

The number of persons who took specified health examination in FY 2012 (National Health Insurance)

Male Female

(persons)


Those aged between 40 and 74, who are either self-employed orunemployed have to be covered by the National Health Insurance scheme,whereby the municipality or special ward is the insurer. Those coveredunder the National Health Insurance can undergo the specified healthexaminations in the community. Based on the results, people receive thespecified health guidance based at a designated institution in thecommunity. The rate of people who undergo the examinations increasewith age from 15% for males in their 40s to 40% in their 70s, and fromapprox. 20% for females in their 40s to more than 45% in their 70s.

* Generally Japanese workers retire at age 60 years. Those who were previouslycovered by an employees’ insurance scheme need to shift to another type ofinsurance after retirement, unless they find another job. One of the choices is theNational Health Insurance.

Source: All-Japan Federation of National Insurance Organizations Report of status of implementation of specified municipal health examination and specified municipal health guidance, FY 2012 http://www.kokuho.or.jp/hoken/public/lib/h24_report.pdf (Accessed January 9, 2015)

(age)

http://www.kokuho.or.jp/hoken/public/lib/h24_report.pdf

The health examination


Those aged between 40 and 74 who are covered by (employees’) medicalinsurance and their dependents are still the target of specified healthexaminations, but not of the health examinations described on this page.Those aged between 40 and 74 who are not the target of the specifiedhealth examination, and those of 75 years or older living in a householdreceiving public assistance benefits are targets for the health examinationrun by the regional authority, and focused on the prevention of lifestyle-related diseases. Some of those who are bedridden at home or whoprovide long-term care for a family member will receive a visiting healthexamination if necessary.The results of the health examinations under this program are followedup in the form of health guidance and education for the prevention oflifestyle-related diseases and improvement of lifestyle.

0

5,000

10,000

15,000

20,000

40-49 50-59 60-64 65-69 70-74 75and over

Number of persons who underwent health examinations (2012)

male female

(persons)

(age)

Source: 2012 Report on Community Health and Health Promotion Programs, MHLW

The health handbook

0

100,000

200,000

300,000

400,000

500,000

600,000

Male Female

age 40-74 age 75 and over


(persons)


The health handbook is issued by the municipality and is intended forpeople to keep a record of health examinations and guidance and otherinformation necessary to maintain their health, and to use to managetheir own health and ensure an adequate level of medical care. Thehandbook is issued free of charge to any persons of 40 years or olderwho have received any of the following services:• Health education, health consultation, functional training, visiting

guidance• Specified health examination, general health examination, health

promotion programThe health handbook also contains information on the prevention oflifestyle-related diseases and the maintenance of health.

The number of people provided the health handbook by municipalities(2012)

Health education in the community

0

20,000

40,000

60,000

80,000

100,000

120,000

2010 2011 2012

Number of group education sessions convened

general periodondal diseaseosteoprosis COPDclassified by clinical condition medication

(persons)

(year)


“general:” Education about the dos and don’ts for everyday life to prevent lifestyle-related diseases, the promotion of health, the ideal diet, and other matters essential to health“classified by clinical condition:” Education about the relationship between individual lifestyles and obesity, hypertension, heart diseases, etc., and how to develop a healthy lifestyle“medication:” Education on precautions when storing drugs and how to take drugs properly,and information about how drugs work and how side effects develop

Source: 2010, 2011 and 2012 Reports on Community Health and Health Promotion Programs, MHLW

The PHN plans, designs and implements group health education eventsand individual health education sessions targeting people aged between40 and 64 years, and reports the outcome of the events and sessions.Group health education is aimed to promote accurate knowledge on theprevention of lifestyle-related diseases and other health-related matters,and to raise participants’ awareness to protect their own health.Individual health education is a continuous health education for thosewith hypertension, dyslipidemia, diabetes and/or a smoking habit tounderstand the characteristics of the concerned diseases inconsideration with the specific aspects of the individual’s lifestyle andother factors.

Health consultation in the community


The municipality conducts the health consultation service to individualswho seek consultation on physical and/or mental health, and thenecessary guidance and advice are given. This service is aimed atsupporting health management at home. The service is staffed by suchprofessionals as physicians, dentists and PHNs. The health consultationservice targets those aged between 40 and 64, who have their abodeswithin the boundary of the concerned municipality.Health consultation services at the municipality level provided in 2012included priority health consultations, the number of persons whoreceived priority health consultation was 532,783 in total. Most of themwere pathology-specific consultations including guidance takingindividuals’ dietary and other lifestyle factors into consideration.

0

50,000

100,000

150,000

200,000

250,000

2008 2009 2010 2011 2012

hypertention dyslipidemia diabetes

periodontal disease osteoprosis women's health

classified by clinical condition

(persons)

(year)

* A “priority health consultation” is held with the focus on one of the following challenges: “hypertension,”“dyslipidemia,” “diabetes,” “periodontal diseases,” “osteoporosis,” “women’s health” and “classified byclinical condition,” selected by the municipality taking the area’s actual incidence status, etc. intoconsideration* A consultation “classified by clinical condition” is held on a specific pathology such as obesity or heartdisease, but does not include hypertension, dyslipidemia, diabetes, periodontal disease, osteoporosis orwomen’s health, and takes the individual’s lifestyle, such as diet into consideration* FY 2010 figures do not include the data for some municipalities in Iwate, Miyagi or Fukushimaprefectures due to the impact of the Great East Japan Earthquake


The number of persons who took priority health consultation

Approaches in the community


Individual approachWhether a person is healthy, can be categorized into the“potential” group of lifestyle-related diseases, or hasalready developed a lifestyle-related diseases, thenecessary information and consultation and/or guidanceservices are provided in accordance with the individual’sstage

Group (community) approachFamilial lifestyle trends, customs in the community, etc.,may lead to the development of a lifestyle-relateddiseases in an individual. That is the reason for this styleof community approach

In the community, the PHN is engaged in effective actions to tacklelifestyle-related diseases while monitoring an entire community throughindividual and group approaches. The PHN endeavors to prevent thedevelopment and exacerbation of lifestyle-related diseases and topromote health by managing people’s lifestyles, ranging from food andnutrition, exercise and sleep utilizing the “sleep guideline”.


Users

Health insurance

Long-term care insurance

Visiting nursing stations, hospitals and clinics

Care managers

Physicians

Written instructions

Home-visitsHome-visits

Requests

Home-visit nursing is covered under the Long-term Care Insurancesystem or health insurance schemes and provided by visiting nursingstations, hospitals or clinics. A physician’s written order is required tostart the home-visits.In home-visit nursing, nursing profession supports users long-termrecuperation at home, striving to provide care to restore and promoteusers’ health while minimizing the impact of their illness or disability.Home-visit nurses provide various forms of care, including managementof chronic conditions and support of family members. Home-visit nursessupport a patient with a lifestyle-related disease, as well as the family, toachieve selfcare, to live with one’s own disease.

Home-visit nursing also supports those living with lifestyle-related

diseases

OCCUPATIONAL HEALTH SUPPORTING THE HEALTH OF

WORKERS


Occupational health and lifestyle-related diseases

Elementary education

Lower secondary education

Upper secondary education

Tertiary education

Workers Retirees

School health service Occupational health serviceCommunity

health service

Health and healthcare services provided at hospitals and clinics


Pursuant to the Industrial Safety and Health Act, occupational healthensures the safety and health of workers at their work places and promotesa more comfortable work-place environment. From the time when theyleave school until retirement, workers are covered by occupational healthservices.Japanese people show a rapid increase in mortality from cerebrovasculardiseases, cancer and heart diseases starting from around 40 years old.Those aged 40 years or older are thus targeted by health examination andguidance services that focus on metabolic syndrome. It can be said thatthose age groups targeted by occupational health services form a significantgeneration in the prevention and management of lifestyle-related diseases.

Nurses and Public Health Nurses are involved in occupational health asoccupational nursing staff. The 1996 revision of the Industrial Safety andHealth Act clearly provides for the PHN as one who implements healthguidance services. The PHN plays a major role in occupational healthservices’ effort to prevent and manage lifestyle-related diseases.

Occupational health coverage

Activity content of occupational health

Work environment management: to prevent health impairmentand to create and maintain a positive work environment. This includes countermeasures against smoking.

Work task management: to improve the work method and ensure adequate work hours and details, thus mitigating work load and reducing any negative impact of labor

Health management: to prevent health impairment by monitoring the relationship between workers’ health and environment/content of work, as well as to maintain/promote health through overall health support activities. Formulation of the health plan, health examinations, health consultations, etc.


Occupational health have three roles: work environment management,work task management and health management. Health managementinvolves a range of actions, i.e., health examination and follow-upmanagement, health guidance, health consultation and healthpromotion from the planning stage to implementation and evaluation.Occupational health are aimed to ensure that workers are healthy andable to work. Health examinations are not only intended to achieveearly detection of any health impacts and monitoring of the workers’health status, but to determine if the worker is able to do his/her taskand can continue with it. Thus the consequent health guidance onlifestyle-related diseases is not only aimed to improve the worker’slifestyle, such as nutrition and exercise, but also to ensure that theworker manages his/her job in accordance with the individual’s status.

Regular health examination

9,000,000

10,000,000

11,000,000

12,000,000

13,000,000

14,000,000

15,000,000

0.0

10.0

20.0

30.0

40.0

50.0

60.0

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

the number of person who took health examination

the rate of abnomal findings in blood pressure

the rate of abnormal findings in blood lipids

the rate of abnormal findings in blood glucose

the rate of total abnomal findings


Source: MHLW Study of occupational diseases occurred between 2004 and 2013 http://www.mhlw.go.jp/bunya/roudoukijun/anzeneisei11/ (Accessed January 13, 2015)

(%) (Persons)

The number of people who took regular health examinations and the rate of abnormal findings

The results from the regular health examination, pursuant to theprovision of the Industrial Safety and Health Act, shows an increasingtendency in the rate of abnormal findings in persons who underwentexaminations. The rate exceeded 50% since 2008. Follow-up after aregular health examination such as health guidance is important forworkers to remain healthy and continue working. The nursing staff inthe frontline occupational health service work in partnership withindustrial physicians to perform interventions that support workers’health.

(year)

SCHOOL HEALTH AND LIFESTYLE-RELATED DISEASES


School health

School health

Health management

Promoting health

Health and safety consideration

Health educationDeveloping

competence in promoting health


School health is health activities provided at educational settingspursuant to the provisions of the School Health and Safety Act. Schoolhealth includes a health education component, namely, health teaching,and a health management component, namely, health examinations topromote health and a safe environment for school activities. Variousmembers of staff and professions are involved in school health, includingthe school nurse-teacher (yogo-kyoyu), who takes the major role inobservation of the health status of school-age children, health guidanceand health consultations. The qualification of yogo-kyoyu requireseducation at a tertiary institution designated by Ministry of Education,Culture, Sports, Science and Technology(MEXT) according to a provisionof the Education Personnel Certification Act, but does not require anursing qualification. However, some universities and colleges with anursing program also offer the education necessary to obtain thequalification of yogo-kyoyu. In addition, a person with the PHNqualification can also obtain a yogo-kyoyu qualification by completingthe required additional education.

Health management


Regular health examinations are implemented topromote the health of school-age children and schoolstaff. The regular health examinations are followed upwith instructions on preventative measures againstand/or treatment for a disease and other measuressuch as reducing one’s exercise or task level.Guidance and management of daily life is alsoprovided for children suffering chronic diseases such asheart diseases, asthma or kidney disease. Whileavoiding excessive restrictions on activities, the child’sschool life is managed through partnership among theattending physician, school physician, home-roomteacher, parents and yogo-kyoyu.

Children prone to obesity

0

2

4

6

8

10

12

5 6 7 8 9 10 11 12 13 14 15 16 17

male female(age)


Source: MEXT Statistical study of school health 2013 (confirmed data) http://www.mext.go.jp/component/b_menu/other/__icsFiles/afieldfile/2014/03/28/1345147_1.pdf (Accessed December 12, 2014)

Childhood lifestyle also affects the development of lifestyle-related diseases. Another important role of the school health is intervention to develop favorable lifestyle of children. Due to lifestyle changes in dietary habits like content of meals and skipping meals, staying up late and not getting enough exercise, actions are required to help children prone to obesity. According to the 2013 School Health Statistic Survey by MEXT, the trend in obesity declined from FY 2006 through FY 2011 but has leveled since FY 2011.

The term “children prone to obesity” refers to children with an obesity index of 20% or higher against the average reference ranges for weight by sex, age and height

(%)

Prevention of smoking habit

0.0

20.0

40.0

60.0

80.0

100.0

junior high school boy high school boy junior high school girl high school girl

Smoking experience(2012)

No Yes Unknown

23

(%)

Japanese Nursing Association

Smoking is one of the causes of lifestyle-related diseases in Japanese. The Act on the Prohibition of Smoking by Minors prohibits smoking by minors under 20 years of age. The Act also states that the retailer of tobacco must check the buyer’s age when selling tobacco, and the retailer may not sell tobacco if a minor may smoke it. Since smoking from a young age has a major health impact and leads to a lifelong smoking habit, education for smoking prevention is important.

Source: 2012 Executive Report on “Study of the situation of under-age tobacco smoking and alcohol consumption:” Grant-in-Aid for Scientific Research from the Ministry of Health, Labour and Welfare (lead researcher: Takashi Ohida, Public Health, Nihon University School of Medicine)

Prevention of an alcohol consumption habit

0

20

40

60

80

100

junior high school boy high school boy junior high school girl high school girl

Frequency of alcohol consumption(2012)

drink nothing once or twice a year onece or twice a month

every weekend several times per week everyday

unknown

(%)


Source: 2012 Executive Report on “Study of the situation of under-age tobacco smoking and alcohol consumption:” Grant-in-Aid for Scientific Research from the Ministry of Health, Labour and Welfare (Lead researcher: Takashi Ohida, Public Health, Nihon University School of Medicine)

The Minor Drinking Prohibition Act prohibits alcohol consumption by aminor younger than 20 years of age. The said Act also prohibits sellingalcohol to a minor knowing that the minor may consume it and providesmeasures to take, such as checking the age. However, as the study dataindicated, alcohol consumption by minors is not zero.

Health education at schools


One component of health education stipulated in MEXT’s curriculum guidelines is health learning about health promotion and disease prevention. Not only home-room teachers and health and physical education teachers, but also yogo-kyoyu may teach this component if they meet certain criteria.

Elementary school:• To keep a balanced lifestyle in terms of diet, physical exercise, rest and

sleep for a healthy life and good physical development and growth• To prevent lifestyle-related diseases, which are mainly caused by daily

living behavior, it is necessary to acquire optimal lifestyle, including a balanced diet

• Such habits as smoking and alcohol consumption may harm one’s health

Lower secondary school:• Disruption in lifestyle such as unbalanced quality and quantity of food in

the diet, lack of physical exercise and lack of rest and/or sleep may cause lifestyle-related diseases

• Smoking and alcohol consumption have negative physical and mental impacts, and may harm one’s health

Upper secondary school:• To promote health and prevent lifestyle-related diseases, it is necessary to

practice a balanced lifestyle in terms of diet, physical exercise, rest and sleep

• Smoking and alcohol consumption may cause lifestyle-related diseases. It is required to have measures for individuals as well as the social environment

Sources:MEXT Curriculum guideline for elementary schoolhttp://www.mext.go.jp/a_menu/shotou/new-cs/youryou/syo/tai.htm (Accessed December 19 2014) MEXT Curriculum guideline for lower secondary schoolhttp://www.mext.go.jp/a_menu/shotou/new-cs/youryou/chu/index.htm (Accessed December 19 2014) MEXT Curriculum guideline for upper secondary schoolhttp://www.mext.go.jp/component/a_menu/education/micro_detail/__icsFiles/afieldfile/2011/03/30/1304427_002.pdf (Accessed December 19 2014)

NURSING CARE AT HOSPITALNURSING TO SUPPORT PEOPLE WHO

LIVE WITH DISEASES


Nursing at hospital

• In the hospital, nurses are mainly involved in caringfor patients with lifestyle-related diseases

• Nurses support patients to learn how to self-manage their lifestyle-related diseases; i.e., byproviding the knowledge and skills as well as thepsychological support so that the patient can makeindependent decisions about everyday selfcare

• The nurse plays the role of coordinator in themulti-disciplinary team


Hospital ward

In the ward, nurses mainly provide the care forpatients in the first (onset) and acute (followingexacerbation) stages.


Outpatient service

Self-management of chronic disease faces suchchallenges as shorter hospital stay leading to patientswho are discharged before acquiring a sufficient level ofselfcare ability and an aging population resulting in morepeople finding selfcare difficult. Nursing intervention atoutpatient service is increasingly required to supportpatients’ continued self-management.

At the outpatient service, the nurse works in partnershipwith other relevant professionals such as physicians,pharmacists and dieticians, and provides consultation andguidance on matters related to home healthcare to post-discharge patients who visit the outpatient service for thefirst time and other patients who need continuousassistance. The nurse aims to learn about the patients’situation by talking with them, and to provides individualcare so that they can continue selfcare of their lifestyle-related diseases.


Nurse-led outpatient services inspecialized field

No2,470 institutions

No-answer/ unknown

50 institutions


Some hospitals have established nurse-led outpatient services inspecialized field.In 1992, guidance by outpatient nursing was first recognized as a type ofcare with an medical fee component under the health care insurancesystem: the home-based recuperation guidance fee. The 2009 JNAsurvey found that 28% of the surveyed institutions had nurse-ledoutpatient services in specialized filed. Although not all of these targetlifestyle-related diseases, there are many outpatient services related tolifestyle-related diseases, like diabetes, smoking cessation, home-basedrecuperation consultation, lifestyle-related diseases, and foot care. Themedical fee revisions have led to an increase in the number of nursing-related medical fee components, which resulted in more hospitalsestablishing nurse-led outpatient services in specialized filed.A nurse has to meet certain criteria to provide consultations and othernursing tasks at an outpatient services that can claim for medical fee.The required criteria includes certain nurse staffing and nurses withadequate experience and training in the respective fields.

Source: Japanese Nursing Association, 2009 Survey on the demand and supply of hospital nurses

Yes975 institutions

Examples of outpatient services• Cancer nursing• Foot care• Diabetes care support • Care for lymphedema• Support for home care • Smoking cessation support

n=3,495

Nurse-led outpatient services

Certified Nurse Specialist and Certified Nurse plays an important role at nurse-

led outpatient services in specialized field


Japan does not have a legal system that recognizes the qualifications ofnurses in specialized fields of practice. Various organizations andprofessional societies have their own system of certification.Credentialing system by JNA is socially recognized and highly esteemed.

Eleven fields of specialized practice are specified in JNA’s credentialingsystem of certified nurse specialist(CNS), while 21 fields are specified forcertified nurses(CNs). Among these fields, the fields of cancer nursingand chronic care nursing for CNSs and the fields of chronic respiratorynursing, diabetes nursing, palliative care, cancer pain managementnursing, breast cancer nursing, etc. for CNs, meet the requirements fortraining: one of the criteria for receiving medical fee for outpatientnursing service. These nurses with certifications also play a major role inproviding high-quality nursing to patients.

Name of certification

Number of fields

Number of educationprograms

Duration of education

Number of certified persons

Certified nurse specialists

11 96 graduate schools256 programs

2 years26 units/ 38 units

1,266(11 fields)

Certified nurses

21 59 institutions104 programs

6 monthsAt least 615 hours

14,263(21 fields)

As of July 2014

Documents

Nursing for the People with lifestyle-related diseases in ... · •Health education, health consultation, functional training, visiting guidance •Specified health examination,